TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 Urgent Services 20 Emergency Services 21 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 Timely Access to Care 22 Cost Sharing 22 Limitation of Liability 23 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 38 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 Eligibility and Enrollm...
TABLE OF CONTENTS PAGE. I Recognition and Scope of Agreement 1 II NJ Department of Personnel 2 III Grievance Procedure 3-7 IV Association Business 8-9 V Bulletin Boards and Access 10 VI Health and Safety 11 VII Insurance 12 VIII Personal Days 13 IX Clothing 14 X Overtime 15-16 XI Union Security 17 XII Discipline 18 XIII Discrimination or Coercion 19 XIV Equipment 20 XV Transfer and Reassignment 21 XVI Out of Title Work 22 XVIII Vacations 24 XIX Longevity 25 XX Holidays 26 XXI Sick Leave 27 XXII Management Rights 28 XXIII Strike Clause-Slow Down-Work Action 29 XXIV Severability 30 XXV Conformity of Township Code 31 XXVI Maintenance of Benefits 32 XXVII Retirement Benefit 33 XXVII Labor Management and Increment Review 34
TABLE OF CONTENTS PAGE. ARTICLE I THE MERGER 2 1.1 The Merger 2 1.2 Effect of Merger 3 1.3 Certificate of Incorporation and By-Laws 3 1.4 Effective Time of Merger 3 1.5 ERS Directors and Officers 3 1.6 Taking of Necessary Action; Further Action 3
TABLE OF CONTENTS PAGE. Section 1. Certain Definitions 4 Section 2. Appointment of Rights Agent 8 Section 3. Issue of Right Certificates 8 Section 4. Form of Right Certificates 9 Section 5. Countersignature and Registration 10 Section 6. Transfer, Split Up, Combination and Exchange of Right Certificates; Mutilated, Destroyed, Lost or Stolen Right Certificates 10 Section 7. Exercise of Rights, Purchase Price; Expiration Date of Rights 11 Section 8. Cancellation and Destruction of Right Certificates 12 Section 9. Availability of Shares of Preferred Stock 12 Section 10. Preferred Stock Record Date 13
TABLE OF CONTENTS PAGE. ARTICLE 1
TABLE OF CONTENTS PAGE. 1 Recognition 1 2 Definitions 1 3 Physical Examinations 1 4 Homebound Teaching 1 5 Summer School 2 6 Purchase of Protective Clothing 2 7 Grievance Procedure 2 8 Worker’s Compensation 4 9 Liability Insurance 4 10 Medical Health Insurance Benefits 5 11 Dental Health Insurance Benefits 7 12 Life Insurance 7
TABLE OF CONTENTS PAGE. 1. CERTAIN DEFINITIONS 1 1.1 Certain Definitions. 1 1.2 Construction. 25 1.3 Accounting Principles; Changes in GAAP. 26
TABLE OF CONTENTS PAGE. 1. Trade Union Recognition 1 2. Definition of Employees 3
TABLE OF CONTENTS PAGE. ARTICLE I. DEFINITIONS 1 1.01
